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Diagnosing skin disorders in patients with skin of colour

Presented by
Dr Deepak Balak, Leiden University Medical Center, the Netherlands
DDD 2024
Inflammatory skin conditions in patients with skin of colour differ from the typical textbook descriptions of patients with white skin. Signs and symptoms can be different and more subtle. Particularly, erythema and photosensitivity may be difficult to perceive in patients with skin of colour. Dr Deepak Balak (Leiden University Medical Center, the Netherlands) provided practical tips for diagnosing various skin diseases in patients with skin of colour.

“There are large differences in the impact of inflammatory skin diseases between individuals with white skin and those with skin of colour,” said Dr Balak at the start of his talk [1]. “In patients with skin of colour, disease severity may be worse, the risk of complications is often increased, and the prevalence is higher for some inflammatory skin conditions.” Dr Balak mentioned that this may be due to genetic factors, environmental elements, socioeconomic reasons, institutional racism, and physician-patient interactions. “In addition, if one googles a certain skin condition, the first 10 pages of images are about skin types 1–3, i.e. white, fair, or average skin colour. Self-recognition of skin disorders is, therefore, more difficult for patients with skin of colour,” emphasised Dr Balak.
Spotlight on dermatomyositis: overcoming educational bias

Skin disorders are more frequently misdiagnosed in patients with skin of colour [2]. Dr Balak argued that perception bias and assumptions may play a role in this matter [1]. “We are driven by what we have learned in our education, mostly studying images of patients with white skin,” according to Dr Balak. “Therefore, our pattern recognition is better developed for diagnosing patients with white skin.”

Using dermatomyositis as an example, Dr Balak emphasised that the recognition of cutaneous signs of this disease is essential because the diagnosis is primarily clinical. Early diagnosis is important since this disease is associated with an increased risk of malignancies and interstitial lung disease. “The lack of educational material to recognise this condition in patients with skin of colour has a negative impact on the diagnostic accuracy of dermatologists.”

According to Dr Balak, dermatomyositis is often confused with eczema in patients with skin of colour. “For subtle presentations of inflammatory skin disorders, it is crucial to postpone quick decisions based on pattern recognition and first gain a full view of the patient,” advised Dr Balak. Heliotrope rash, Gottron’s papules, Gottron’s sign, cuticle abnormalities, shawl sign, midfacial erythema, V-sign, holster sign, and inverse Gottron’s papules are signs to pay extra attention to in patients with skin of colour. Moreover, ulcerated Gottron’s papules are typical of anti-MDA5-dermatomyositis, a variant of the disease associated with interstitial lung disease in Asian patients.
Cutaneous lupus erythematosus

“Cutaneous lupus erythematosus can often be distinguished from dermatomyositis by looking at a patient’s hands,” mentioned Dr Balak. “We see Gottron’s involvement of the knuckles in dermatomyositis, whereas the skin between knuckles is involved in patients with cutaneous lupus. According to Dr Balak, acute cutaneous lupus erythematosus is hard to recognise in patients with skin of colour, because the signs are often subtle. “We should always screen patients with acute cutaneous lupus erythematosus for systemic involvement,” emphasised Dr Balak. The most common subtype of cutaneous lupus erythematosus in patients with skin of colour is chronic discoid lupus erythematosus (CDLE). It is characterised by atrophy, scarring, pigment shifts, and sometimes vitiligo-like de-pigmentation with a hyperpigmented edge. “In patients with localised CDLE, systemic involvement is rare,” added Dr Balak. “For generalised CDLE, the risk for systemic lupus erythematosus is approximately 20%.” Another difficult-to-recognise and less frequent subtype of cutaneous lupus in patients with skin of colour is melanotic lupus erythematosus. “This variant is mostly documented in patients from India,” said Dr Balak.
Psoriasis and atopic dermatitis

Further, Dr Balak briefly described that psoriasis is often characterised by less notable erythema, thicker plaques, more desquamation, scalp involvement, and shifts in pigmentation in patients with skin of colour. “In Asian patients, we see the so-called small plaque-type psoriasis,” added Dr Balak. Tinea corporis, hypertrophic lichen planus, and cutaneous lupus erythematosus are typical differential diagnoses.

Dr Balak mentioned that atopic dermatitis is highly prevalent in patients with skin of colour, but the erythema is often less notable. On the other hand, xerosis cutis and lichenification are often more prominent in these patients. “We also see papular and follicular presentations of the disease,” added Dr Balak. In contrast to patients with white skin, symptoms occur more frequently on the extensor side of joints than on the flexor side. Psoriasiform eczema is often observed in patients with skin of colour.
Recognising rosacea

“Finally, contrary to common views, rosacea occurs in patients with skin of colour as well,” according to Dr Balak. Papulopustular and granulomatous phenotypes are most common in these patients. “Flushing is less frequently reported, which may be related to differences in endothelial function,” explained Dr Balak. Importantly, rosacea in patients with skin of colour is associated with the use of corticosteroids, demodicosis, and sun exposure.

  1. Balak DMW. Inflammatoire huidaandoeningen bij patienten met huid van kleur: praktische tips voor Dermatologendagen 2024, 11–12 April, Amsterdam, the Netherlands.
  2. Groh M, et al. Nat Med. 2024;30(2):573-583.

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